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Post DBS STN Depression

This case report discusses a 51-year-old male with 11 years of Parkinson's disease who experienced severe motor response fluctuations, dyskinesias, and subsequently developed depressive symptoms after undergoing bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN). Despite the surgical procedure improving his motor performance, the patient exhibited apathy, sleep disturbances, constant suicidal thoughts, and aggressiveness without response to SSRIs. The report emphasizes the dissociation between motor and affective symptoms in DBS patients and highlights the need for proactive, varied therapeutic approaches to manage post-DBS depression.

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Post DBS STN Depression

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  1. Post DBS STN Depression Doron Merims , Yacov Balash Nir Giladi Movement Disorders Unit, Department of Neurology, Tel-Aviv Sourasky Medical Center.

  2. Case report • 51 year old male • 11 years Parkinson’s disease • Motor response fluctuations • Severe dyskinesias • Freezing and festinations

  3. No History of depression • Never in his life mentioned suicidal thoughts

  4. Treatment • L-dopa • Amantadine • Selegiline • Requip • 15 Apomorphine injections / day

  5. Bilateral Deep brain stimulation to the Sub thalamic nucleus. • Unremarkable postoperative course. • Gradual improvement of motor performance: no fluctuations ; no dyskinesias

  6. Post DBS • Dopicar ½ X 5 • Amantadine 100mg X 3/D

  7. Post DBS • Depressive mood • Apathy • Sleep disturbances • Reduced appetite • “Pressure” of constant suicidal thoughts • No response to SSRI’s

  8. Behavioral and Affective changes • Depression and suicide attempts • Mania • Aggression • Marked improvement of severe OCD in patient with advanced PD

  9. Post DBS STN Depression • Stimulation induced? • Drug alteration? • Other?

  10. Stimulation induced depression • N Engl J Med 1999 340;1476-1480.

  11. Drug alteration?Reward System • limbic system • The nucleus accumbens • ventral tegmental area

  12. Review of 16 articles describing 31 patients

  13. ELLDOPA – A new concept • A third type of symptomatic benefit from levodopa • 2-week washout was not sufficient to return treated patients to the placebo level • “The duration of this benefit is unknown, but it probably lasts longer than one month.”  Fahn S, The seventh international congress of Parkinson’s disease and movement disorders. Miami Florida 2002.

  14. conclusions • Post DBS STN is not a rare phenomenon • Dissociation between motor and affective signs • The patients are in a high risk for suicide attempt • The efficacy of SSRI’s is low • Therapeutic approach should be prompt, aggressive and consider different etiologies

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